Measuring prevalence of D&A during childbirth in Tanzania: The Staha Project

1. Measuring prevalence of D&A during childbirth in Tanzania:The StahaProject Respectful Maternity Care seminar GWU Miliken School of Public Health June 24, 2014

2. The task The landscape analysis CATEGORIZED types of D&A reported in the literature. The definition must provide the CRITERIA that an incident or condition must meet in order to qualify as D&A.

3. The definition should: • Capture structural D&A as well as individual D&A • Enable multiple disciplines (e.g., law, human rights, public health) to use their tools to address D&A • Enable measurement of D&A • Do no harm. Definitions shape the narrative and “appropriate” the experience of D&A

4. Building blocks for defining D&A A list of observable actions/behaviors, some of which are context specific Actions that are experienced as disrespectful or abusive Intentional infliction of pain or emotional distress or humiliation, either by commission or omission Facility conditions and clinical treatment that do not meet accepted/consensus standards found in the human rights documents, national law, policies (AAAQ).

5. Individual level Structural level Policy Level Defining disrespect and abuse in facility-based childbirth Individual level: actions that all agree are D&A Initial intervention target Prevalence Measure Policy Advocacy Individual level: Normalized D&A: What women experience as D&A but providers consider normal When providers are disrespectful and abusive but women consider it normal Structural level: What women and providers consider poor care, but is caused by system deficiencies Structural level: System deficiencies that lead to poor care that is accepted and normalized Deviations from national standards of good quality care Deviations from human rights standards (available, accessible, acceptable, quality)

6. Study setting – Tanga Region Tanga region, Tanzania population: 2,010,480* * 2011 estimate by the National Bureau of Statistics based on the 2002 Population and Housing Census

7. Study setting: Korogwe and Muheza, Tanga Muheza: comparison Korogwe: intervention population: 341,166* population: 324,000* 4 Sites: District hospital 2 health centers 1 dispensary 4 Sites: District hospital 3 health centers * 2011 estimate by the National Bureau of Statistics based on the 2002 Population and Housing Census

8. Facility exit interviews (N=1,779) Women approached after discharge from 8 study facilities Interviewed in tents outside of the facility for privacy and convenience Response rate: 71% Advantages Can obtain a large sample in a limited amount of time Reduces potential for recall bias Cost-effective

9. Community follow-up interviews (N=593) Subset of women from facility exit interview sample Interviewed 5-10 weeks postpartum in their homes Interviewed about D&A, health seeking behaviors, postpartum depression Response rate: 76% Advantages Provides an environment where women may feel more secure to share their experiences Allows women more time to reflect on their experience/adjust to newborn

10. How were women asked about D&A? A) Single question: asked the following question before any specific D&A questions were asked At any point during your stay for this delivery, were you treated in a way that made you feel disrespected or abused? B) Experience of D&A events Now we’re going to read you a list of things that sometimes happen to women who have given birth in a facility. For each of these things, please tell me if you have experienced it during your recent delivery at this facility. Please keep in mind we are talking about this delivery and not your past deliveries. Example: Health providers threatening to withhold treatment because patient could not pay or did not have supplies.

11. D&A categories and events in questionnaire NON-DIGNIFIED CARE • Shouting at/scolding patient • Threaten to withhold treatment • Negative comments to patient • Threatening comments to patient • Ignoring patients requests for assistance • No attendant at delivery NEGLECT PHYSICAL ABUSE • Hitting/slapping/pushing/pinching, etc. • Rape • Sexual abuse • Stitching of episiotomy without anesthesia • Discuss patient’s private health information in public • Share patient’s health information • Patient’s body seen by others NON-CONFIDENTIAL CARE • Tubal ligation, caesarean or hysterectomy without consent NON-CONSENTED CARE INAPPROPRIATE DEMANDS FOR PAYMENT • Request bribes/informal payments • Mother or baby held at the facility due to failure to pay

12. Facility exit vs. community follow-up: prevalence of D&A by experience

13. Maternity ward observations (N=310) Women observed from active labor to 2 hours postpartum at 2 hospitals Capture observable events of D&A and their context using same list of events as on facility exit/community follow-up questionnaire Same women are then interviewed on exit by a different person 77% of women who were observed participated in the exit survey

14. Observation vs. facility exit: prevalence of D&A by experience

15. D&A prevalence measures

16. D&A measures Self-report single item (n=240) Self-report single item (n=1,779) Self-report any D&A (n=1,761) Observed any D&A (n=310) Facility Self-report any D&A (n=240) Self-report single item (n=593) Self-report any D&A (n=592) Community

17. D&A measures by source 4.2% Self-report single item (n=240) Self-report single item (n=1,779) Self-report any D&A (n=1,761) Observed any D&A (n=310) Facility Self-report any D&A (n=240) 6.3% 19.5% 71.3% 10% Self-report single item (n=593) Self-report any D&A (n=592) Community 12.7% 28.2%

18. Complexity of Care Environment Same nurses who observed 70% any D&A Observations of respectful maternity care (N=310)

20. Conclusions and recommendations • Women’s experiences matter • Women’s own judgments are shaped by local norms of behavior, normalization, expectations, and system constraints • Observations tell us more about the care environment • The single-item question may be a proxy for measuring normalization and expectations of the system • Used in other settings (Uganda, Tanzania, Zambia) and reveals similar results • The question can be further tested • D&A is one component of women’s delivery experience • may be more useful to consider D&A as part of a “dignity of care” scale that also contains RMC items.

21. Thank you

22. Extra slides

23. Types of physical abuse (N=47) • Examples: • Slapped to push: • when pushing the woman tightened her legs, the nurse slapped her on her thigh and told her to open her legs • Push you idiot! I am going to slap you. She hit the woman on the head. The woman was not pushing. • Slapped to cooperate: • The woman was causing trouble when the nurse was performing the vaginal test, the nurse slapped her twice on the thigh • She slapped her when she failed to go up on the delivery bed • Slapped – other: She slapped the patient after refusing to be given anesthesia injection which caused the nurse to inject herself • Pushed: Move there, why are you so naïve? Is this your first time? Sit properly. The nurse pushed the woman

24. Types of threatening (N=55) Examples: Scare tactics: If we don’t do that you will get some slight pain, we are stitching you without local anesthesia, if you don’t do this your partner will run away from you because your sexual parts will be very large You will kill your baby if you tighten your legs Threat to hurt or abandon: I will beat you, when the woman refused to open her legs I will leave you because of your noises, I will stop helping you and go to sit Traditional herbs: You are going to die if you don’t want to speak the truth. Did you take traditional herbs? Other: After you finished here, go to the family planning clinic or I will put a method in you

25. Types of negative comments (N=113)

26. Types of negative comments Patient attribute: Where did you find this dirty mackintosh, it looks like a canvas of rain! What tribe do you belong to that you cant understand Kiswahili? Are you Mang’ati or..? Look how you are suffering with that abdomen, that is the result of rushing into life. How are you going to take care of the children? Noise: The patient was calling for the nurse, the nurse told her, why are you crying while others have been seen and they are not making noises? Other – mild: Bring your waist down! It’s as if you are dancing. Many pregnancies: You have delivered several times, this is your eighth pregnancy and you don’t know how you can get sterilized? Don’t you get this training from your home? This is your sixth pregnancy and you come for delivery with only 2 kangas and your pants so dirty? Ignorance: You are a teacher and you pretend not knowing where the baby is passing? It will pass from down there. Reference to sex: Why are you tightening your legs? My fingers are not big like the penis that entered here. Other – severe: The woman had a slight tear, she was afraid that the nurse wanted to stitch her. The nurse told her, “for your information, your husband is going to leave you and look for a beautiful woman with a tight vagina”

27. Observations: main findings • More individual episodes of D&A observed than reported by women: • 32% of observations recorded 2 or more D&A events on observation vs. 21% of self-reports on exit • No correlation between observations and self-reporting on exit (chi-square, paired t-test) • No clear pattern of associations between demographic factors and reports of any D&A on observation

28. Why is the observed any D&A much higher than the self-report any D&A? Measurement error? Measures something different?

29. Measurement error? Observer Validity • No association between number of hours observed and report of “any D&A” by observers • Removing 3 “outliers” did not change results Data quality assurance • Two people coded contextual information provided by the observers to determine if event was D&A • Recoded any events that were not D&A or wrongly categorized • Recoding did not significantly affect “any D&A” measure or individual events of D&A

30. Measuring something different? Observers were highly sensitized to detect D&A – many marginal events recorded Observers were not asked to rate the severity of the D&A they observed and women might only recall events they perceived as severe Observers were not asked to rate the quality of care for labor overall Observers and women are not reporting the same events as D&A

31. Women’s reports of satisfaction and quality of care: comparison across study samples a Versus somewhat satisfied, somewhat dissatisfied, very dissatisfied

32. Recent development: Influence of post-partum depression In community follow-up survey, women were asked questions from the Edinburgh Post-partum Depression Scale (10 questions) Of the women who met the criteria for postpartum depression, more of them reported D&A on follow-up than they did on exit Women were 3 times more likely to be depressed if they reported D&A on follow-up

33. Proposed next steps • Develop and test a “dignity of care” index • Combination of D&A and RMC concepts/events • Include questions on trust, support, humane care • Test index in a population-based sample in 1-2 countries • Explore how this index is linked to longer-term effects on care-seeking

34. Facility exit interview waterfall analysis Women discharged from study facilities (n=2,673) Women approached for interviews (n=2,520) 698 did not agree to participate 1,822 (72.30%) women agreed to participate 43 had a tablet malfunction/record lost 1,779 women interviewed

35. Community Follow-up Waterfall Analysis Women who consented to be followed and completed the facility exit survey (n=1532) Randomly selected for follow-up (n=915) 133 lived outside the study districts or remote areas and were deemed ineligible Eligible for follow-up (n=782) • 190 were not interviewed: • 149 not found • 23 missing data • 7 refused consent • 6 mother or child dead • 4 not followed 593 (75.83%) interviewed for community follow-up